Jeremy Youde '99 presented "Ebola, the World Health Organization, and the Chances of Reform" on Sept. 8, 2015, as part of the Rosenfield Program's Global Public Health Symposium.

Transcript:

- [Voiceover] All right, we're gonna start soon.

- [Voiceover] Okay.

- [Voiceover] So we'll give it like three more minutes, because we have a decent showing at 4:00.

- [Voiceover] Sure. No, they actually start at the same time but there's all different blocks, that all the blocks have changed. And then they end up 3:15 instead of 4 or 5.

- [Voiceover] Oh, yeah. I think that would mess up

- [Voiceover] Yeah.

- [Voiceover] Which is like basically things can change.

- [Voiceover] They cut down on the lunch a little bit.

- [Voiceover] Oh, okay.

- [Sarah] Okay, I think I'll start my intro, if that's all right?

- [Voiceover] Go for it.

- [Sarah Purcell '92] Good afternoon, everyone. Thank you for joining us for the exciting start of our Global Public Health Symposium. I'm Sarah Purcell, Director of the Rosenfield Program in Public Affairs, International Relations and Human Rights, and we are extremely pleased to be co-sponsoring this week's and next week's symposium with the Luce Program in Nations and the Global Environment with President Kington, with Grinnell Wellness, and then also with some special funds contributed by the John Chrystal Fund for Distinguished International Visitors. It's a mouthful, but lots of people have joined together to bring us this very exciting program.

I have a couple of housekeeping things to mention before I introduce this afternoon's speaker, the first of which is that this afternoon's talk is being live simulcast to high school students around the country who are part of the Global Online Academy, so we welcome our livestream viewers. And they are able to access this speech to contribute to a global health class and to get acquainted with Grinnell College and what the co-curricular programming is like. So we're very pleased that they can join us. They may be live tweeting in questions. We'll see if that works, I'm gonna try to do that, and let me remind you that the hashtag is #youdegc, Y-O-U-D-E-G-C, if you want to live-tweet in a question. You here in the room may ask a question in person, you don't need to live-tweet the question.

I know that we have such a great turn out, we actually ran out of programs, I apologize for that, but we do have the poster on the back table listing the rest of the events. My beautiful assistant is holding it up, listing the rest of the events for this week and next. We will have more programs for tomorrow, so stay tuned. I promise we'll have more to hand out tomorrow. I will remind you that the next talk will in fact be tomorrow at 7:30pm, when Clemencia Aramburu will be speaking about public health, disaster relief and health in Latin America, and so I hope you'll be here for that. And I also want to just keep reminding everyone through this week that our final keynote talk by Dr. Paul Farmer, the co-founder of Partners in Health, is not this week, but next week. So it's Friday, September 18th. Make sure you mark your calendar for next Friday. I don't want anyone showing up at the Harris Center unless you're going to a movie or something else this Friday. But next Friday you should come for Paul Farmer, so we'll look forward to that.

It's been such a great pleasure in putting together this symposium to have an especially large group of distinguished alumni come for this symposium. We found that there are so very many important Grinnell alums working in the field of public health, in all different sectors of public health, and our first talk this afternoon features one of the best. We're very proud to have him and very pleased to have him back at Grinnell.

Jeremy Youde is Associate Professor of Political Science at the University of Minnesota Duluth. He did indeed graduate from Grinnell in 1999 with a B.A. in Political Science and a concentration in Global Development Studies. And he also has a Master's Degree and Ph.D. from the University of Iowa. He also taught at Grinnell College, both as an instructor and as an assistant professor before moving on to University of Minnesota, so when I say we claim him as our own, I really, really mean it.

He is the Department Head of the Department of Political Science and also Acting Director of the International Studies Program at the University of Minnesota Duluth. And I'm telling you a newsflash, that he will actually be leaving the University of Minnesota Duluth in January to move to a new position in Australia at, I'm going to say the wrong...

- [Jeremy Youde] Australian National.

- [Purcell] Australian National University. And so that was like a real gasp from the crowd. I like that. So we're pleased that we got him here while he is still just one state away rather than several continents away. But I have told him already that he has to return in the future, nonetheless, so.

He has already had a very distinguished career and is really a foremost political science expert on the politics of global health. He is the author of, or co-editor of at least five books, including The Politics of Surveillance and Responses to Disease Outbreaks, The Rutledge Handbook of Global Health Security, Global Health Governance and Biopolitical Surveillance and Public Health in International Politics. It made me want to read every single book on his CV. He has written widely on many, many different topics, including MERS, global health governance, biosurveillance, disease and surveillance, and many other very interesting topics. There wouldn't be time for me to list the amount of grants that he's received, but as a Grinnell alum and a former teacher here, I was particularly proud to see that he won the 2012-2013 College of Liberal Arts Teaching Award, and also was named Outstanding Faculty Member at the University of Minnesota Duluth for 2010-2011.

He's a frequent commentator and contributor to the public debates about global public health, has been published in the Washington Post, and talks frequently to many other press outlets. But we're extremely lucky to have him kicking off our symposium today, so please join me in welcoming back to Grinnell Professor Jeremy Youde.

- [Youde] Oh wow, thank you so much, everyone, for coming out, and thank you for that incredibly generous introduction. I can't say that I've ever had my own hashtag before, so if for nothing else, that's very exciting to be here. And it's particularly gratifying for me to come back and speak about this topic today, because in many ways this is a return to where it all started.

So we go back about 20 years or so. There's a much younger me hanging out in Zimbabwe on the ACM Zimbabwe program, which I think is in Botswana now, if I'm remembering correctly. But this was during the spring of 1998, and this was really the first place that I started to explore this connection between political science and health. During that program, there was a one month independent study and I did my independent study project on the political and economic effects of HIV/AIDS in Zimbabwe. That's what got me started looking at these issues in Southern Africa, which got me to my dissertation topic, which got me into everything that I've been doing since, which ended up bringing me here so this very much is a very welcome return to where a lot of my career started.

And so, what I want to talk about today is I want to talk about the World Health Organization. I want to talk about the current and ongoing Ebola outbreak. And I want to talk about what this outbreak might mean for the World Health Organization. In particular, what sort of insights we can glean from political science and international relations to understand how and why reform may or may not happen and what sorts of reforms may actually be important here.

So the headline takeaway from everything that we've seen so far is that in this Ebola outbreak, the World Health Organization has basically failed, that its response has been lackluster at best, that it's been slow, it's been driven by conflicts and disagreements within the organization, and it's led to all sorts of calls for serious and major reforms to the organization: changing the structure, adding new structures, adding new organizations, people even calling into question the very existence of the World Health Organization and whether or not it still makes sense in the current time and place. And so we've seen a lot of these discussions that have been taking place at all sorts of levels, in the popular press.

We've also seen efforts to analyze the World Health Organization response led by various think tanks. The World Health Organization itself is undergoing this independent review process, so lots of discussions and lots of conversation around whether or not we need to make reforms. My takeaway from a lot of this at this point is that essentially I would call myself an optimistic pessimist or a pessimistic optimist about the possibilities of reform. In general, yes, reforms need to take place. There need to be some serious changes to how the World Health Organization operates, and the Ebola outbreak has brought to attention some of these problems, some of these flaws that exist with how the organization is currently structured. The problem, though, or the issue is, as I want to argue it, is that the reforms that have largely been proposed don't get at the underlying issues. They're not really addressing the problems that led to this lackluster response, and without some other more far-reaching changes, it's unlikely that we're going to see those sorts of changes or those sorts of reforms taking place. I think it's possible that it still could take place, I think there are opportunities for that, and I'll talk about that towards the end, but at this point, with what we have seen proposed so far, I'm not very excited by the idea that serious and significant changes are going to take place.

So that's what I want to posit here. But before we jump into things, I wanted to also posit a few key parts of this argument.

First, I want to argue that there is an international society. This is something that sometimes comes up, questions about whether or not states are really working together. Yes, I want to argue that, yes, there is this international society and we can use the Hedley Bull definition that we've got a group of states conscious of certain common interests and common values that come together to be bound by common rules and sharing the workings of common institutions. Basically, "Hey guys, we're all in this together, "so let's find some way to work on this issue "that we agree is something that is important." So, I think that's the first thing I want to posit.

Second is I wanna posit that one of those key elements, one of those key institutions that the international society is concerned with, and has really only become concerned with over the last 20 years or so, is this idea of global health governance. So when we're talking about global health governance, we're talking about a group of formal and informal rules, institutions, organizations, processes by which states, inter-governmental organizations, non-state actors, come together to deal with health challenges that require cross-border cooperation. So we're talking about this constellation of groups or constellation of organizations that are coming together because they say, "Hey, no one state can take care "of these health issues on its own. "We're going to have to work together." And this is something that's relatively new to the international agenda. It's really only been over this last generation or so that we've really seen this coming onto to the stage, and that has effects for why the World Health Organization works or doesn't work as it does under the current crisis.

The third issue, the third idea that I wanna posit is that even though this global health governance system doesn't really have a hierarchy per se, there's no formal leader necessarily. The de facto leader is the World Health Organization, so when we're looking at how the international community has responded, how global health governance systems are responding to some sort of cross-border health issue, we're largely looking to the World Health Organization. That is our go-to. That is, when the World Health Organization starts to take action or starts to call something an issue, that's when the international community really gets on board. And it's this process where things kind of broke down, where this sort of operation didn't really come into fruition as we would have hoped it would have when the Ebola outbreak began. And I think a lot of that, if we wanna try to understand why that happened, why this failure took place, is I think global health governance is kind of in its awkward teenage phase right now. In that the World Health Organization has been around for awhile, you know, a lot of these institutions that come to work on global health issues have been around for awhile, but it's only over the last 20, 25 years that we've really come to expect them to do more and to assume this level of primacy within the international system, and they're still trying to figure out what that means.

In a system where you still have sovereign states, where you still have governments trying to figure out what their relationship is with international organizations, with non-state organizations, and just how this whole process is going to work. So part of the problem is that this was one of the really big tests, one of the first big tests. There have been two or three big tests that global health governance has had over the past 25 years. This is the most recent of them, and it didn't really do all that well. So I would say that that's partly because we're still trying to figure out exactly how all of this is going to work out.

All right, so I want to talk a little bit about the actual outbreak itself. I want to talk about the World Health Organization, how it's structured, some of the calls for reform, and then some of what I want to argue would be more likely to lead to some measure of success going forward. S

o to talk just briefly about Ebola itself, you know, most of us probably are familiar with the disease and what it is at this point, but we're talking about a viral hemorrhagic fever. You can see some of the symptoms that are appearing up there. Of course, it's important to remember that this is not an airborne disease. This is something that's spread through close contact with infected bodily fluids, so you're not going to get this walking down the street next to someone. But this is part of the reason why healthcare workers have been particularly vulnerable to Ebola, because of their close contact with people who are ill with the disease. Family members who are taking care of those who are sick also tend to express a higher rate or higher likelihood of becoming infected with the disease.

When we're looking at the infection, generally within 2 to 21 days is when we start to see the symptoms appear, and that 21-day period is really important because that's seen as the outer limit of when you're going to express symptoms, between when you're exposed to the virus and when you're likely to see symptoms. Because we need to go through that cycle twice for the World Health Organization to declare a country to be Ebola-free. So you've gotta go 42 days in order to make that happen, and that has all sorts of potential complicating factors.

One, because you've got to have all these very intense sorts of interventions, trying to keep people from contracting the virus as they are working with patients, and then with the bodies of those who have died, but also it means that you have to keep up these systems even after the need is apparently gone. So it's not immediately apparent, you're not seeing people who are sick. There's a tendency, a very understandable tendency to want to relax some of these sorts of precautions, and that can't happen. That's the sort of thing that can allow for the disease to take root again.

At this point, we don't have a cure. Most of the treatment is going to be palliative, trying to take care of the symptoms. We've seen some experimental treatments. We've seen some efforts on vaccination, which are very promising, but again, this is very much in the early stages, and that's not something that everyone necessarily has access to. So we're talking about a virus which in previous outbreaks has had upwards of 90% fatalities. With this current outbreak, we're looking at something closer to about 40% based on the numbers that the World Health Organization has provided.

Now, part of the reason that this has been such a challenge is that this is a relatively new disease. So you can see on the map there the town in the middle, Yambuku, that's where Ebola was first discovered in 1976. That's where we start to get the first medical reports of the disease. Interestingly enough, they named it Ebola after the river, which is nearby, because they didn't want to name it after the community out of fear that there could be some sort of stigma attached to the community if they named it after that location. So they figured if we used a river instead, that will give us a little bit more flexibility. People are less likely to be stigmatized by it. But, like I said, 1976 is when we get these first cases reported in the medical literature. So we're not talking about a disease that has been known for a very long time.

We're also talking about a disease which, for as fearsome as it is, we haven't seen a huge number of cases. We're talking about roughly two dozen, if that, outbreaks in humans since that first outbreak in 1976, and up to that point, in terms of the number of deaths, we've seen somewhere in the neighborhood of about 2,000-2,500 cases, and about 1,900 people dying of the disease. So incredibly fearsome, you know, all sorts of scary imagery, for understandable reasons, but also incredibly rare, and that also has an effect on the readiness that international institutions have for dealing with something like this.

It's also not something that we'd seen in West Africa before, so that also has an effect. This is not something that clinicians would necessarily be expecting to pop up, so that has an effect as well. There's a lot that we don't know about the disease yet. For instance, we're not entirely sure where it hangs out when it's not in humans. So this is a zoonosis, so it's a disease that's coming from animals. That's not all that crazy. About 75% of human infections are transmitted from animals, so dogs, chickens, pigs, these sorts of creatures, these are the things that tend to be these carriers of these illnesses. So if you want to avoid avian influenza, you know, don't make out with your chicken. That's gonna be one of the safest things to do.

But with Ebola, we don't quite know yet where it hangs out. Chimpanzees and bats are the most suspected animal reservoirs for the virus, but, again, we don't entirely know yet. And we're still trying to work through some circumstantial evidence to try to figure out what is going on, and how and under what circumstances it makes that leap, the virus makes that leap from its animal reservoir to humans.

So this current outbreak that we're in right now in West Africa begins in December of 2013, where we get a child who falls ill and dies of what later turns out to be Ebola in Guinea. Then the child's family members start to fall ill and die, and so we start to see, you know, a number of cases. And initially, like I said, this is not necessarily assumed to be Ebola because this is not where Ebola typically resides. This is not an area that has seen Ebola cases. So we get this first child dying in Guinea in 2013. Excuse me. And just to kind of put this into some perspective here, so the marker there is Meliandou, the village where the first child died of Ebola in December of 2013, and one of the first things that becomes really apparent about the location of that is that we're right near international borders.

So we've got Guinea, Sierra Leone, and Liberia, all basically coming together right there where those first cases are starting to appear, and these borders are relatively porous borders. There's a long tradition of people going back and forth for commercial reasons, for family reasons, for all sorts of reasons. This is a well-traveled area, and so that automatically introduces a complication because it's one thing to try to deal with an Ebola outbreak within a single country, to try to get a government on board, to get a public health service onboard. It's another thing to try to coordinate that among multiple governments, and then bringing the international community onboard on top of that. So lots of difficulties there.

So, December, 2013 we get the first, what we now know, the first cases of Ebola. On March 23rd we get the first report from the World Health Organization. They send out a report because Ebola is one of those automatically notifiable diseases. If there's a human case of Ebola, you've got to tell the World Health Organization. So on March 23rd of 2014 we get the first published report from the WHO reporting that there have been 49 cases and 29 deaths in Southeastern Guinea. A week later, we get the first cases in Liberia. So, again, that border already starting to come into play because we've got those first cases reported a week later. A few days later, we get the first cases popping up in Sierra Leone. So within a few weeks of these first reports coming out, we've got cases popping up in three different countries.

We get the first regional meeting of health ministers in July of 2014, and in August of 2014, so eight months after the first cases and five or six months after the first notification from the World Health Organization that there are these human cases of Ebola, on August 8, 2014 the World Health Organization declares a Public Health Emergency of International Concern, PHEIC. And this, under the international health regulations, this is kind of what gets things started. This is when the World Health Organization is basically saying, "Hey, world. "We've got a situation here. "We need to mobilize resources. "We need to get things going." Excuse me.

And so this is when we start to see those pleas coming out from the World Health Organization asking for resources, asking for personnel, because the World Health Organization doesn't have those things sitting around. It doesn't have reserve funds. It doesn't really have all that many employees that can go out into the field itself. So when they make this declaration in early August of 2014, this is what really jumpstarts things. A month later, on September 18, 2014, the U.N. Security Council declares Ebola a threat to peace and security. This is the first time that they ever have actually used that language, that an infectious disease is a threat to international peace and security. They've kinda talked about it with HIV/AIDS a few years prior, but it's always been couched in terms of peacekeeping missions, or in terms of vulnerabilities among various populations. This is the first time in a resolution they actually explicitly used that language, and so that helps to ramp up some of the attention here.

So we see this process happening where we're trying to raise funds, countries are pledging funds. We're seeing personnel from states, but also non-state actors getting involved in this. And many of the non-state actors have been involved well before as well.

Fast forward to May 9th of earlier this year, Liberia was declared Ebola-free. They had gone that 42-day period without any cases, and that lasted about a month and a half. And then new cases appeared in Liberia, so they had to rescind that declaration, obviously, and just this past Thursday, Liberia was again declared Ebola-free. And we'll see how long, whether or not that continues, because Guinea and Sierra Leone are not yet Ebola-free.

So if we look at, this is the most recent numbers from the World Health Organization. They come out every Wednesday. So tomorrow we'll have some new numbers, and there's a little bit of lag there. But what you can see here is we've got about 28,000 cases and about 11,000 deaths throughout this whole process, and the vast majority of these cases, of course, in Guinea, Liberia, and Sierra Leone.

Just to drill down on the three most infected countries in some more detail, you can see in the middle, whoops, you can see in the middle there, with Liberia, this is why they were able to be declared Ebola-free, because we've got this long period of time without new cases.

Guinea, the numbers are going in the right direction. You know, we're going from a dozen, two dozen cases, down to just a handful that are appearing each week, but those are still new cases that are appearing every week.

Sierra Leone, things were going really well. A new case popped up at the end of August, and then actually when I was driving down this morning there were another four cases that were being reported by the Ministry of Health.

Now what sort of communication there has been with the World Health Organization yet is still a little unclear but we've still got a bit of time before we can call this outbreak completely over. From the World Health Organization's perspective, though, things have not been good. These were just ... If you Google WHO Ebola failure, things come up pretty quickly. There are lots of things to choose from, and these are just some of the headlines that I just cut and pasted from various sources. So you get this language about failures prompting the WHO rethink, it was this big failure, that it's acknowledged its failure, utter failure, accused of failure, all sorts of horrible things.

So what are these failures? What is it that they didn't do well? Well, everything, but what's the, what are the serious things? So, one thing is a significant delay in actually mobilizing resources and attention.

So we get that first report from the WHO in March, and then we're going almost five, six months before we actually get that Public Health Emergency of International Concern declared. And during that time period, we've got a lot of back and forth, a lot of bureaucratic tussles and things like that, but what it meant was the organization wasn't mobilizing. It wasn't calling the attention to the international community in the way that we would expect it to as the leader of global health governance.

Second is a sheer lack of resources. WHO, you know, it doesn't have these sorts of financial reserves available, it doesn't have the personnel reserves that it can deploy on a moment's notice, but also it just doesn't have much control over its budget. The World Health Organization has a relatively small budget, and it controls very little of it, so it doesn't even have the resources to do the sorts of things that we expect it to do. Now, some of that is, you know, we lay at the feet of the international community. Why aren't you giving the resources there? We'll talk about why some of that is in just a minute.

Third is that the response was seen as being too political, that there was too much of an emphasis on the potential economic and political effects of making this declaration of a Public Health Emergency of International Concern. That's something that's come out in some of these reports that have been commissioned about the response, that people are saying, "Well, we heard about this, "but we were afraid that if we did something, "that would devastate the economy of these countries. "That would make them international pariahs." Yes, that's reasonable, but so is having an untamed outbreak of Ebola. So there's a problem there, that this political consideration got in the way.

And then, finally, the other issue that has been identified is that the WHO has not been giving enough incentives for states to make these reports. That states are supposed to come forward with this information when they have these outbreaks of Ebola or some of the other infectious diseases, and the argument is that the way that the WHO has been structured, because of these other sorts of issues, states are reluctant to wanna actually engage with that process. And if states aren't engaging with that process, then it's hard for the whole mechanism to actually do what it needs to do.

So, the big takeaway here is that the WHO hasn't done a super stellar job. So, let's talk a little about WHO itself and how it's structured and why it may have ended up in that sort of circumstance.

So the WHO is one of the specialized agencies of the United Nations. It was one of, if not the first, of the specialized agencies proposed. Proposed in 1946, and interestingly, even though it was the first proposed, it was the last to have its constitution ratified. It didn't come into existence and start to operate until 1948, and the reasoning behind that really gets into some of the emerging tensions around the Cold War that we were starting to see in the immediate aftermath of World War II. There were suspicions about what sort of a mission the World Health Organization was going to have. Was it going to be more of a technical organization? Was it going to be getting inside the countries and trying to tell them how to set up their health systems and insurance systems and all these sorts of things? So there was a lot of push back initially when it was initially proposed, but in 1948 it did finally come into existence when its constitution was ratified. And that constitution explicitly states that the World Health Organization's mission is to act as coordinating authority on international health work. So that's what it is charged to do, that is its mandate, and it works with all of its different member states.

So the way the World Health Organization is structured is that anyone who is a member of the United Nations also is a member of the World Health Organization unless they specifically decide to opt out. Then they also have additional members who are associate members, who don't have full membership within the United Nations. So there are some Pacific Islands which have membership in WHO, but do not have membership within the broader United Nations. Puerto Rico has membership in WHO on its own. There is one country in the world which is a member of the United Nations and has opted out of being a member of the World Health Organization, and it's Lichtenstein. Why Lichtenstein has opted out, I have never been able to figure out. No one has been able to give me any sort of rational explanation, but it's a country about the size of this room with about the same population, but for whatever reason, this is where it's decided to opt out. So they're off doing their thing right now, I guess.

So we've got our 196 members, and the organization is structured where we've really got two big centers of power.

One is the World Health Assembly, and the World Health Assembly comes together every May in Geneva, those poor souls. Representatives from each country come together in Geneva for two or three weeks to basically set the organization's agenda. And the World Health Assembly is structured much like the General Assembly of the United Nations: one country, one vote. So everyone's on the exact same playing field regardless of how much money you're giving, political power, anything like that. So their job is to kind of set the stage for what the World Health Organization is going to do. And that's where a lot of the debates about the important issues really take place.

The other big important center of power within the World Health Organization is the Director General, and the Director General is the equivalent of the Secretary General of the United Nations. This is the person who is leading the organization, who is the public face of the organization, and is ultimately responsible for the overall operation of the organization. Excuse me. So right now Margaret Chan is the Director General of the World Health Organization. She has held that position since 2007. She was re-elected to the position in 2012, and most people assume that this term that she is in will be her last. So there are five-year terms of office. Most observers assume that when she's done with this term in 2017, that someone else will step in.

Margaret Chan has a public health background, as many, but not all, of the Directors General of the World Health Organization have had. She came up through the Hong Kong Public Health Service, and then also through the WHO's service itself. So she's someone who's very much steeped in public health and has really gone through that process. It's also kind of interesting, she was someone who was promoted heavily by the People's Republic of China as their preferred candidate for Director General in 2007 when they were looking for a new Director General, and in part that's because China got kind of a black-eye for its response to SARS. And so this was kind of its attempt to sort of, "No, actually we're cool with everyone. "We wanna play along." And so Margaret Chan has been in that position since 2007.

So, the World Health Organization is headquartered in Geneva. You know, we've got the World Health Assembly that meets there every year. We've got the Director General who oversees things, but it's really hard to speak of the WHO as a single organization. In many ways, we could think of it as this sort of seven-headed beast, because in addition to the Central Office, the Central WHO office in Geneva, each region, each of the six regions, has their own regional WHO. So in the Americas we have the Pan-American Health Organization. In the Western Pacific it's the Western Pacific Regional Office.

So each of these regions has their own WHO, which is largely autonomous from the Central Office. They have their own budget. They have their own Director General. They set their own agenda. And they may or may not work with what the Central Office wants to do. They're not always in line with each other, and there have been times when they've actually been fairly diametrically opposed to one another, and the reason for this is largely historical. Some of these organizations existed before the WHO came into being, or they grew out of existing organizations, so rather than trying to wipe those old organizations out of existence, they basically tried to encompass them, tried to bring them into the fold. But, like I said, what it means is that you end up with seven different organizations that are all speaking for these cross-border health issues that don't always necessarily agree with one another.

In terms of financing the WHO, this is the budget that they're currently working on. So we're talking about a bi-annual budget, so we've got a budget for every two years. And you can see up there, the WHO's budget has been declining in recent years. Part of that is a reflection of some of the economic challenges that we've seen over the past decade or so, but part of it is also about a judgment about where countries are giving their money, and I'll talk about that in a little bit here. But you can see we've got this decrease in its budget, and you can see over here where that decrease had to go, where they ended up cutting resources for things. So communicable diseases had a bit of a cut, about an 8% cut. Communicable diseases would be those things that transmit from one person to another person. And then over here, losing more than half of its budget, I'm not sure if you can quite read that in the graphic there, outbreak and crisis response. So that would be the people that are supposed to do the sort of thing that we would expect WHO to be doing when something like Ebola breaks out.

Why is it like this? Why would we have such a funky sort of arrangement? It's because the WHO is funded in two different ways, and those two different ways don't necessarily play nicely with one another. So, in the green here, we've got the assessed contributions from member states. Those are dues. Every country has to pay a certain amount into the WHO, just by virtue of membership, like they do with the United Nations, like with most other international organizations. And that amount is going to be determined based on the size of the economy, population. There's a few other factors that they put into that. So everyone is expected to pay that, just by virtue of membership. The big blue part there, the voluntary contributions, that's where things get kind of funky, because those are contributions that come largely from member states, but also from private organizations. The Bill and Melinda Gates Foundation, for instance, has given money directly to the WHO.

What's significant about this is that with these voluntary contributions, these extra budgetary funds, WHO has no control over those. Donors say, "This is how we want that money spent. "We will give you $5 million for malaria control efforts." Very rarely does that money go into the core budget. The green part there, the assessed contributions from the member states, that's what WHO has control over. That's the budget that the World Health Assembly gets to debate every May and gets to set.

So, to go back here, with that pie about how the WHO's budget is allocated, most of that money is coming from the priorities of specific states that have voluntarily opted to give that money to the WHO for their priorities. Those priorities may or may not necessarily line up with the priorities of WHO or WHO member states. And WHO, again, doesn't have control over those funds. States may have all sorts of reasons that they wanna give that money to WHO. "We think it would be more effective if we could "go through these multilateral channels. "We wanna take advantage of the expertise "WHO may have on these areas." All sorts of various reasons may go into that, but, at the end of the day, you end up with a situation where you have an international organization which has a relatively small budget, $4 billion over two years. So we're not talking about an incredibly wealthy organization, and the members themselves have control over very little of that budget, they can set the priorities over just a very small portion of that.

That process, this imbalance here has been... We've had this opportunity for states to give voluntary contributions since WHO was created. That was something that was built into the charter. You start to see an increase in the voluntary contributions in the 1970s. In the 1980s, that's when we start to hit parity between the assessed contributions and the voluntary contributions. Since that time, the proportion of voluntary contributions has steadily increased. So this pie chart here is from 2006-2007. At this point, the assessed contributions from member states is closer to about 20% to 23% of the organization's overall budget. The rest is coming from these voluntary contributions. And so, all of these sorts of issues that I'd mentioned about how things are set up, they all contribute to the ability of the organization to respond. You know, why do you have to cut outbreak and crisis response so much? Well, you only have control over that very small portion of your budget. Why don't countries give money to outbreak and crisis response? Because that's not sexy; no one wants to give millions of dollars for outbreak and crisis response because that doesn't generate the same sort of attention as polio eradication, or smallpox eradication did in the 1970s and the 1980s, or any of these sorts of things.

So we've got an organization which is hamstrung by the priorities of its member states, and the priority of a small group of member states. That amount that's going in the voluntary contributions, that's coming from about 20 to 25 states and a few private organizations. So we're talking about a very select group that is getting involved in that process. But that regional organization, that regional structure that I mentioned, that also contributes to the problems because we had cases here where the Regional Office for Africa wasn't working well with the Central Office in Geneva, and vice versa.

So, they were not calling meetings, there were government officials who were putting up roadblocks, literal and metaphorical roadblocks to try to get personnel and supplies into these regions, and WHO couldn't do that much about it. They could say this is really inconvenient, that you're not helping us out here, but they didn't have any real leverage over that. Margaret Chan is, you know, in many ways has done an admirable job in a horrible circumstance, but she's someone who comes up through a public health background as opposed to a political background, and she's also coming as someone who is sponsored by China, coming from a country that is less interested in flexing its muscle within the organization because of fears that people may get concerned about what that sort of influence may augur for the future. So the P5 countries, the Permanent Five countries, tend not to want to lead these sorts of reform efforts.

So we've got a leader who relatively politically doesn't have much political influence and power. We've got a budgetary structure which is completely out of whack, and we've got an institutional structure that doesn't allow the organization to speak with one voice, and that contributes to a lot of these sorts of issues that have come up.

So, to talk real briefly about some of the proposed things that have been suggested for making changes, one thing is creating a reserve fund, a $100 million dollar reserve fund that would be available if an outbreak occurs. We can do this, we can respond quickly, and we won't have to go to the rest of the world to get that money. This again would be funded by voluntary contributions. So, in theory this could be funded, but whether or not countries would step up, or if they'd be willing to replenish it, is completely up in the air.

Second, they've talked about the creation of essentially a rapid ready force of epidemiologists and public health folks who could be deployed at a moment's notice to provide personnel in necessary regions. Again, because WHO doesn't have its own personnel, it's asking countries to provide this sort of support and make these people available. And, again, on a voluntary basis, so whether or not they'd be willing to do that is a challenge, to be sure.

And then finally they've talked about trying to insulate the organization politically, trying to insulate some of these decisions about making these Public Health Emergency of International Concern declarations, make it so that they're taken out of the political realm, taken out of the economic realm, and they can just decide this based on science. As much as we may not like to admit it, though, an international organization, be it devoted to health or any other issue, is inherently political. The idea that you're going to be able to abstract politics from this organization and suddenly everything is going to work well is just not feasible. And what you'd end up doing instead is adding extra layers of bureaucracy trying to create this buffer zone of some sort that would be able to look at some sort of objective data and make this sort of decision where that just doesn't speak to how things actually operate, especially within these international organizations.

So these proposed reforms that have come up, it's not so much that they're bad, it's just that they don't get at the underlying issues. It's that they don't actually address the things that have really hampered the ability of the WHO to reform.

So what sorts of things would I propose? Let's say I'm taking over WHO because, you know, once you've taken Grinnell you can take over WHO, what will I do? So there are three things that I would focus on.

One is changing the budgetary structure. Now, in order to do that, member states would have to vote to do that. They would have to vote to change how dues are assessed to themselves, and they have not been willing to do that since the early 1980s. So getting that through is probably unlikely to happen. But, there could be an opportunity for changing some of the rules and regulations around voluntary contributions, mandating it so that if a country is giving a voluntary contribution, some portion of that at least is going into WHO's core budget, so it can at least have some control over that. That would be a less radical step, but would also be something that would allow WHO to be responsive to the member states that are giving these voluntary contributions, but also getting control over its budget.

Second thing is that through any of these reforms we need to have some sort of state entrepreneur, someone to really lead this charge, and that's something that was really striking in this most recent World Health Assembly. For all the talk about we need to change the WHO, we need to have some sorts of reforms, no one's been stepping up to do that. No state has stepped up to really provide the leadership. You might be thinking of the U.S. or the U.K. or France or something like that would do that, they're not really structurally in a good place to do that. The countries that might be able to do that would be some of these countries that are in blue, countries that are known as middle powers. The middle powers are often seen as sort of the international boy scouts or girl scouts of the international community, the ones that take on these tasks that can help to foment change within these organizations, in part because they're seen as being... Everyone likes them. I mean, Australia, New Zealand, you know, Canada, these are the countries that are typically seen as middle powers. Who doesn't like Australia and New Zealand and Canada? I mean, they're countries that can negotiate, can act as these go-betweens between the really powerful states, but also some of the smaller states. We need some sort of state entrepreneur like that to step up, someone to take this on as an issue, because without that this is just going to be something that flounders within these conversations. We're going to get lots of reports, but we're probably not likely to see significant changes taking place.

The third thing that I would propose is, so we've got a new Director General who will be coming in in 2017. Let's get a politician in there. Let's get someone who can actually talk the political talk. You know, we can separate this out so we've got the Director General, who is almost the equivalent of a CEO, and then have someone who has more of the public health background as the COO, or something along those lines. But we need someone who is able to engage governments on that level, who has a certain level of creditability that public health officials simply may not have. They may not have access to those sorts of resources. And where we saw WHO really starting to flex its muscle again during the 1990s, a lot of that was coming out of Gro Harlem Brundtland, who was the Swedish Prime Minister who took over WHO and had that sort of conversation, was able to engage governments on that sort of level.

Three people that might be good candidates for that, both because of the countries that they come from and because of their experiences, we've got Helen Clark there, who is in the corner, she's the former Prime Minister of New Zealand. She is currently the Director of the U.N. Development Program, so she may be interesting because she'd also have some experience with the U.N. bureaucracy and understanding how that works out. There's also certain conversation that people may wanna put her forward as the next Secretary General of the U.N., so maybe she might not want to make that move.

Over here on the right-hand side we've got Julia Guard, who's the former Prime Minister of Australia, someone who has some health background, not a strong, extensive period. The question that would really come up there is whether or not Australia would be willing to champion her given that the government in Australia is currently led by the liberals and she comes out of the Labor Party, so there may be some weird sort of political dynamics there. There's also the whole internal dynamics with Australian politics and how she lost her job, and all this sort of stuff. So she may have some political baggage, but she understands political baggage, and that may be something that we need in this position.

And then the third person in the center here is Johanna Sigurdardottir. I probably butchered that, and I apologize if anyone here actually speaks Icelandic. She's the former Prime Minister of Iceland. She's the person who took over... We had the financial crisis here and Iceland collapsed. She was the person who stepped in when Iceland collapsed, so she knows how to take on thankless tasks and try to right these ships. She's 72 at this point, so she may not necessarily wanna take on something like WHO, but, again, she's someone who understands how that process works out.

So, just to wrap up here quickly, WHO does need to reform, and the Ebola outbreak showed that WHO is not necessarily structured in such a way that it can respond to these sorts of emergencies. A lot of these calls for reform, though, I think are responding to what has happened in the past, and wouldn't make the organization responsive to things that are going to happen in the future. These are backwards-looking as opposed to forward looking. We need to think more about the structural and political elements that affect how and why the World Health Organization is able to operate. So these are proposed reforms. Not bad, they're just insufficient, and we need to go deeper, essentially, if the World Health Organization is going to be able to reclaim its place of prominence.

Global health governance is unlikely to go away. Health issues aren't going to stop being cross-border issues any time soon, so we need to find some way to do this that we can have something ready and able to respond when these sorts of crises pop up, because another one will pop up. It won't necessarily be Ebola, but there will be something else, and so we need to find a way that we can deal with that in a much better solution as opposed to what we've seen with the Ebola outbreak. Thank you.

- [Purcell] Thank you so much. That was really great. We definitely have time for questions. It is very important that you speak into the microphone for a question, however. So, Andy Casey has the microphone. Raise your hand, I will recognize you, and she will come around. Over here. I will watch for Twitter questions.

- [Voiceover] Okay, so you showed a map of the World Health Organization regional map, and in it Africa was divided into two, the East Mediterranean thing. I understand why maybe Egypt and Morocco would be put in that category, but places like Somalia and Sudan, I don't understand. So could you explain the criteria for this categorization?

- [Youde] Yeah, that's an excellent question. So this division between why you have Africa split up between two different regions, some of it's about politics, and that also goes to, you know, you can't quite see it on the map here, but, for instance, Israel is lumped in with the European Region, and that's a political decision. Southeast Asia, North Korea's part of Southeast Asia, so some of that's about these sorts of political decisions that get made. Why exactly they made that split exactly how they did, you know, it's not entirely clear. My guess is that what happened is this was how people wanted to split things as countries were becoming independent, you know, during the 1950s and the 1960s. There may be some sense about if there are shared linguistic elements or there are things like that to try to facilitate communication and cooperation that way. But a lot of it ends up with just kind of a, "Well, we've gotta divide it somehow," and so this is kind of how some of those get drawn, but then, I mean, you've got Algeria there in the middle like they're gonna be with the rest of Africa, so. Again, there are all sorts of weird things within these U.N. bureaucracies that maybe made sense at one point, but don't necessarily make a ton of sense with the current structure.

- [Voiceover] Hi, I just wanted to say thank you for the talk. So, my question is actually last year we, for the African Caribbean Student Union, we had an Ebola talk and we had a panel of professors who had their opinions. So, I was wondering what your opinion is. One professor said that if Ebola like had an outbreak in Beverly Hills, the response would have been faster. So, do you think that maybe the stigma that is attached to where, of course the continent, like, "Oh, there already are diseases there," do you think that the stigma attached to it also had a part to play in the response gap that was there between what you wanted to happen? Because I think most cases started coming up when, you know, a patient flew in to Hong Kong or flew in to the U.S. or went to Spain, when the responses were much faster. So do you think that, in your opinion, I was wondering what your opinion is.

- [Youde] Yeah, I think that's probably a sad fact that part of the response is premised on these sorts of assumptions that people have about Africa as a continent. And we thought, especially in some of the early days, we saw these horrible reporting about the descriptions of Africa and the descriptions of how people ate and how they cared for their sick and the dead, and all these sorts of things, and it was just the... It just it showed a lack of understanding, and then had the following effect because even good faith efforts then are tainted because, "Why should we trust the WHO for coming in "to have this response, because they were really slow "to do this in the first place?" So I think it does matter where things popped up. I mean, even look at what happened in the media coverage when we saw the cases popping up in the United States and the sort of panic there. Interestingly, when the outbreak was really beginning going last August, I happened to be out in D.C., and I was having a meeting with a colleague of mine and she was telling me about an organization that she worked with that were sending personnel over to Liberia to get used bed sheets, and I was like, "Oh, okay. "So, you know, well, that's something that healthcare "clinics need, clean bed sheets and things like that. "That makes sense," she says, "No, no, no. "That's not what they're doing. "They're doing that because they're going to "take those clean bed sheets because they're afraid "otherwise terrorists are going to get them "and turn Ebola into a biological weapon." And that's, I mean, that's the sort of, you know, if that's the mindset that's going in, just the thinking about political stability in the region and there's these sorts of actors who may be involved in it, that's going to lead to a distorted sort of response. So, sadly, yeah, I would have to agree with the person that said that if these cases came out in Beverly Hills or some place like that, that we'd probably see fast responses. This is the same thing that Stephen Lewis, who was the U.N.'s envoy for HIV/AIDS, said about the initial response to HIV, that if the disease had first appeared in Western Europe, there would have been a much faster response. The fact that the cases were appearing in Africa, we lollygag. We didn't see it as being quite as vital to respond.

- [Voiceover] So my question is about the role of media. And do you think, even though the reportings were late, like March, that's the question I had that was absolutely ridiculous, but that's beside the point, do you think the role of media was more facilitating panic than volunteers or assistance? Do you think media played a role of more increasing panic or like getting more volunteers to go help?

- [Youde] Yes. I think that we can almost divide that into two different responses. I think that, in many respects, the media images were useful as a way of generating that attention. You know, even if WHO isn't responding, even if we're not seeing these sorts of things, as we're seeing personnel on the ground and as we're seeing the effects there that are happening, even though there's some squeamish ethical issues about some of the pictures that appeared on newspapers about people who had died or were seriously ill and their ability to consent to those sorts of images being taken, I think that did raise a level of awareness that may have helped to place some pressure on governments to say, "Yes, this is something that we need to deal with." On the other hand, I mean, do you remember last fall and the panic about Ebola coming to the United States and how many of us were going to get sick? There was one poll that they polled Americans and 60% of Americans expected that they or someone that they knew would come down with Ebola. You are going to be attacked by a sharknado is more likely than an American getting Ebola, especially if you're in United States. You know, have you had close contact with the bodily fluids of someone who has been in one of these affected regions? No? Then don't worry about it. But that's not the message that that we got from a lot of these sorts of media responses. You know, I say this as now someone who has his own Twitter hashtag, but I think some of the Twitter responses were also less useful, because then you start to see these rumors that would pop up and they bubble up, and even though they could be dispelled after a while, it just, you know, we'd see something pop up on Twitter then it will be reported in the media about these Twitter rumors and then that would have to, and then a day later or so they'd have to go back and say, "Oh no, that's actually not the case." But, you know, it's just once we're talking about the idea of Ebola in the United States, I think they did an absolutely horrible job and just it was probably more panic than anything else. But I do think that it did have an important effect on a larger stage in some of the earlier parts of the outbreak when there wasn't really much of a response to speak of, but I think it did help to bring home the need for some sort of response.

- [Voiceover] Just speaking in relation to like the question earlier about if the outbreak had been in Beverly Hills, so what is the WHO doing about supporting national governments in creating infrastructures, medical infrastructures?

- [Youde] Yeah, that's an excellent question, this idea about what WHO can do for national infrastructures. That's probably the most important thing that needs to happen, not just in these affected countries right now, but in general.

One of the fears that I have is with, you know, some of these specialized treatment centers that have opened up dedicated to Ebola, the Ebola treatment centers in the affected countries, they're great for Ebola, but do they do other things? Can they take care of other health issues? And if we can build up these infrastructures, we can have something that can be more resilient, that can be adaptable and flexible to whatever sort of things come up. It's unlikely that we're going to need dedicated Ebola treatment centers in this region, but we do need to make sure that there is access to healthcare, just basic healthcare, were large, not just in this region, but around the world.

That's one area where WHO has done some work on that, but, again, it's not the sort of thing that has generated a lot of attention from donors, and so they're limited in what they can do. A lot of what they've been able to do up to this point has been to focus on information sharing. "Hey, this is what has happened in this country. "These are the challenges that they face. "Here's how they overcame that," and so trying to facilitate those conversations. They can't necessarily support the infrastructure itself, they don't have the resources to do that, but they might be able to facilitate some of the information so that countries can work on rebuilding it.

They may be also be able to work on some of these broader issues that affect national healthcare infrastructure, like brain drain, trying to deal with what sorts of incentives may exist, so that people are able to practice medicine and practice healthcare in places like Liberia, as opposed to going to the United States or to the U.K. or places like that. That's a bit more of a macroissue that WHO has had some conversations around how do we deal with brain drain.

So, yeah, infrastructure is absolutely an important issue, one that's probably getting less attention but, you know, at least with, say, the funding that the United States gave for Ebola, part of that funding was dedicated for training healthcare workers and for trying to make sure that that infrastructure sticks around afterwards. Whether or not that's successful is another thing, but there's at least some recognition of that.

- [Purcell] We're going to take two more questions, one over here and one in the very back, so go ahead.

- [Voiceover] So, obviously, an informed public can help to alleviate certain situations regarding outbreaks. With respect to that, can you speak to how the CDC informed, you know, basically the U.S. public with respect to not only the outbreak in West Africa, but the potential for individuals coming from West Africa and how we, as a nation, should be responding? I have an opinion, which is essentially the CDC dropped the ball very dramatically and confused the situation more so, but I'd like to hear your opinion.

- [Youde] Yeah, the CDC is in kind of an interesting position, in part because their own budget for international and global health issues is pretty substantial. So, you know, they've definitely got a role to play. I think that Tom Frieden, who's the Director of the CDC, who came out of I think the New York City Public Health System previously, I think that in trying to alleviate or prevent panic from taking place, I think they may have gone too far in the other direction in saying, "Well, there'll never be a case that happens here." And then there were cases that did start to appear, and I think that it ended up just being a difficult strategy, one that they were kind of fine-tuning on the fly and that's not necessarily getting it all that right. But it's difficult, and this is something that I still struggle with, and I'm sure that CDC and other organizations do as well, is communicating nuance with something like this that does the possibility exist that there could be cases that appear in the United States? Yes.

Should that be something that we panicked about? No. Finding that nuance has not really been the strong suit of CDC or WHO, to a large degree, and I'm not sure how much of that is about a failure on the part of these organizations, a failure on the media, a failure on our, excuse me, a failure on the part of our media literacy, where exactly that falls. But, yeah, the nuance just didn't come through and then you ended up with these situations where it made CDC look like they didn't know what was going on. They didn't understand what was happening and how much they did is another question, but they didn't project that sort of authority that we would look to them to be able to communicate in this sort of a crisis.

- [Purcell] Last question.

- [Voiceover] Thanks to the Grinnell Prize Fellowship, last year at this time, or as the U.S. media was reporting, you know, Ebola number of cases in the hundreds, switching to the thousands, I was flying to Ghana, and every morning, when I'd wake up there, you know, at first I was like scared of going there because of the U.S. media portrayal of what was happening in West Africa. And for the first five days, every day I would wake up and be like, "Is Ebola in Ghana? "Is Ebola in Ghana?" And then after about five days, I realized that no one in Ghana was worried about Ebola coming there, and then I kind of got over it for the rest of my time there. And I say that because I was used to what the U.S. media was portraying right before I went there compared to what the media was reporting in Ghana. It wasn't in the media in Ghana, really, and about the only change that I saw while I was there was that universities had cut back, set back their start dates because of people coming from other countries. Other than that, life was going on as normal as far as I could tell, from what I knew, and I was just curious like now Ghana has yet to have a case of Ebola and being right in the midst of everything. So, even though changes weren't huge and there wasn't a huge scare amongst the people living there, why they were successful in not getting Ebola?

- [Youde] Yeah, I think a part of it's about transportation, I think a part of it is a demonstration effect, and I think that actually was the most stellar response to all of this was what we saw in Nigeria, because that was, when we saw a case pop up in Nigeria, that's where people really started to flip out because, you know, Lagos was just this massive, massive city and if we're not able to, you know, if it gets out into Lagos, you know, it's just going to be all over the place. And what we saw is that a lot of those tried and true epidemiological techniques, that sort of shoe leather epidemiology, contact tracing, keeping and monitoring people, doing these sorts of things, really do make a dramatic difference. And it is also part of the reason why a lot of the recommendations have avoided trying to go to shutting down public places and things like that, because part of what they want to do is make sure there's still access to people, that people aren't feeling some sort of shame, that they're not going underground, that they're not trying to avoid these sorts of situations. So I think that, to some degree, the fact that things got so out of hand in these other countries, and that Nigeria had shown an ability to basically stop things in their tracks, provided a nice demonstration effect to the other countries, to show them like, "Okay, we've seen sort of "the poles of what these sorts of responses could be. "We've seen where the success seems to exist."

- [Purcell] So I want to remind you to come back here tomorrow night at 7:30 for our next talk, which will be on Latin America, and especially to thank Professor Youde for the wonderful talk, thank you so much.

- Thank you all for coming.

- Great, thanks for coming.

- Thank you so, so much.

- Keep watching, but I think a lot of people are going to watch it on...